Lumi Eyes – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you under the care of a physician or taking any medications? *

Yes

No

Have you had recent cosmetic treatments (PRP, Botox, fillers, threads)? *

Yes

No

If yes , write details :

Treatment Goals and History

Have you had under-eye injectable treatments before? *

Yes

No

If yes, what product and when?

Do you currently use eye creams or topical treatments? *

Yes

No

Procedure Information

Lumi Eyes is a polynucleotide-based injectable designed for the delicate under-eye area to rejuvenate and improve skin texture, hydration, and elasticity.

The treatment involves a series of small injections using a fine needle or cannula around the orbital area.

Mild swelling, bruising, or tenderness is common after the procedure and may last up to several days.

Multiple sessions are often recommended for optimal and long-lasting results.

Risks, Side Effects, and Acknowledgements

Read and check the statements : *

I understand that Lumi Eyes is an injectable treatment and results may vary from person to person.

I acknowledge that common side effects include swelling, bruising, redness, or mild discomfort.

I understand rare risks include allergic reactions, prolonged swelling, infection, or nodules.

I agree to follow all post-treatment instructions including avoiding makeup, exercise, and sun exposure for 24-48 hours.

I confirm that I have disclosed all medical conditions, medications, and allergies to the practitioner.

Client Declaration and Consent

Check all Boxes *

I declare that the information I have provided is accurate and complete.

I understand the Lumi Eyes procedure, its benefits, risks, and expected results.

I have had the opportunity to ask questions and voluntarily consent to receive massage treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date

I agree to terms & conditions provided by the company.

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